Things You Need To Know About HCC Coding, Risk Adjustment, And Physician Income

A suitable and sufficient Risk Adjustment Solution enables healthcare professionals to harness their statistical information across the data flow and boost their retrospective and prospective operations. It also aids in ensuring that reimbursement is both appropriate and cost-effective.

A successful Risk Adjustment Solution stipulates that the recipients' health issues, health outcomes, and demographics in a Medicare Advantage (MA) and Affordable Care Act (ACA) program are cautiously recorded. The healthcare practitioner who administers those recipients is sufficiently reimbursed for the monitoring and management.

Hierarchical Condition Categories (HCC), a Risk Adjustment (RA) model that has been here for quite a while now, had gained much traction when MA Plans began requiring RAF scores for financial compensation. Medicare is advocating for additional value-based initiatives to lower net costs and enhance the quality of treatment for Medicare beneficiaries. Healthcare payers are also cutting costs after adopting value-based reimbursement strategies.

Understanding HCC Coding:

Centers for Medicare and Medicaid Services (CMS) utilizes HCC Coding to compensate Medicare Advantage plans depending on their enrollees' healthiness. It accurately reimburses for patients' estimated cost spending by altering reimbursements according to demographic data and patient health conditions. The risk evaluation data is based on diagnostic data derived from claims and health records gathered by physician offices,. inpatient and outpatient visits, and clinical settings.

The Secret of Success Is Accuracy

According to the CMS-HCC model, physicians must accurately report accurately on each patient's risk adjustment diagnosis. In other words, each individual diagnosis generates the RAF, and the score is used to assess payers coverage and potential future spending associated with each patient.

HCC Coding Solution:

1)      The HCC Coding Solution helps to verify patients' HCC grading status, which, when correctly documented, will enhance the patient population's aggregate RAF score and represent premium funds.

2)      It detects patients that have HCC coding potential while they are in the physician’s exam room

3)      It verifies that practitioners receive a complete amount of income owed to them for diagnoses and delivering care.

Physician’s Income:

Medicare Advantage providers quite often offer commercial plans, and it is arguable how closely MA physician income matches Traditional Medicare (TM) rates vs. negotiated commercial rates. However, the TM's administratively established rates serve as a critical foundation for physician compensation under the MA system, even while MA insurers successfully lower costs for other medical services that TM overspends. 

Changes in policy that shift the MA program toward specific premium support alternatives might significantly impact how physicians and some other practitioners are compensated.